DOCSLIB.ORG

Essentials of Sepsis Management

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Essentials of Sepsis Management Essentials of Sepsis Management John M. Green, MD KEYWORDS Sepsis Sepsis syndrome Surgical infection Septic shock Goal-directed therapy KEY POINTS Successful treatment of perioperative sepsis relies on the early recognition, diagnosis, and aggressive treatment of the underlying infection; delay in resuscitation, source control, or antimicrobial therapy can lead to increased morbidity and mortality. When sepsis is suspected, appropriate cultures should be obtained immediately so that antimicrobial therapy is not delayed; initiation of diagnostic tests, resuscitative measures, and therapeutic interventions should otherwise occur concomitantly to ensure the best outcome. Early, aggressive, invasive monitoring is appropriate to ensure adequate resuscitation and to observe the response to therapy. Any patient suspected of having sepsis should be in a location where adequate resources can be provided. INTRODUCTION Sepsis is among the most common conditions encountered in critical care, and septic shock is one of the leading causes of morbidity and mortality in the intensive care unit (ICU). Indeed, sepsis is among the 10 most common causes of death in the United States.1 Martin and colleagues2 showed that surgical patients account for nearly one-third of sepsis cases in the United States. Despite advanced knowledge in the field, sepsis remains a common threat to life in the perioperative period. Survival relies on early recognition and timely targeted correction of the syndrome’s root cause as well as ongoing organ support. The objective of this article is to review strategies for detection and timely management of sepsis in the perioperative surgical patient. A comprehensive review of the molecular and cellular mechanisms of organ dysfunc- tion and sepsis management is beyond the scope of this article. The information pre- sented herein is divided into sections devoted to definitions and diagnosis, source The author has nothing to disclose. Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Suite 601, Charlotte, NC 28203, USA E-mail address: [email protected] Surg Clin N Am 95 (2015) 355–365 http://dx.doi.org/10.1016/j.suc.2014.10.006 surgical.theclinics.com 0039-6109/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. 356 Green control, fluid therapy, antibiotic therapy, and organ support for clarity of discussion, but the practitioner should understand that these approaches occur simultaneously at the bedside, and each action is related to, and should act in concert with, the others. DEFINITION AND DIAGNOSIS The most important aspect of intervention in sepsis is early recognition of the signs and symptoms of the condition. Reducing time to diagnosis and initiation of therapy for severe sepsis is considered a critical component of mortality reduction.3 The Society of Critical Care Medicine and the American College of Chest Physicians proposed standard definitions of this illness spectrum in a consensus published in 1992. The systemic inflammatory response syndrome describes an immune response consisting of 2 or more of the following: Temperature greater than 38C or less than 35C Heart rate greater than 90 beats per minute Respiratory rate higher than 20 breaths per minute or a PaCO2 below 32 mm Hg Leukocytosis of 12,000/mm3 or less than 4000/mm3 This inflammatory reaction in the presence of infection is known as sepsis. Compli- cations of organ failure and hypotension constitute severe sepsis. Finally, septic shock is defined by severe sepsis accompanied by hypoperfusion and organ failure refrac- tory to fluid resuscitation.4 As with all clinical maladies, a focused history and physical examination can provide vital information about potential risk factors for infection and the most likely site of origin. Several clinical clues may support the clinician’s suspicion of infection. For example, unexplained tachycardia is frequently the first indicator of inadequate organ perfusion or a hyperdynamic state of inflammation and should be thoroughly investi- gated in a perioperative patient. Septic patients, unlike those in cardiac failure or hemorrhagic shock, frequently have warm skin on examination because their periph- eral vasculature is not constricted. Acute glucose elevation can be a predictor of infec- tion and should raise the provider’s suspicion when present.5 Inadequate urine output, while useful in monitoring volume and perfusion status, is a late finding in sepsis and septic shock. Sepsis in the surgical patient is likely an underappreciated cause of morbidity and mortality in the perioperative period. In the postoperative period beyond 24 hours, sepsis is by far the most common cause of shock. Sources include surgical site infec- tions, catheter-related bloodstream infections (CRBSI), pneumonia, and urinary tract infections. Moore and colleagues6 found that the abdomen was the most common site of infection in their general surgery ICU population, accounting for 63% of cases, followed by the lungs (17%), wound/soft tissue (10%), urinary tract (7%), and all other sites (4%). In fact, the authors demonstrated that the incidence of sepsis and septic shock exceeded those of pulmonary embolism and myocardial infarction by 10-fold. Gram-negative species were the most prevalent culprits, particularly in abdominal sources of sepsis.6 An understanding of the patient’s recent clinical trajec- tory is invaluable, particularly in the perioperative period. Host defense mechanisms can be compromised by many factors, including surgery, implanted devices, or previ- ous antibiotic use. Knowledge of the patient’s surgical history can give clues to mental status changes, increased minute ventilation, decreased urine output, glucose intoler- ance, thrombocytopenia, or gastrointestinal failure. Appropriate cultures should be obtained before initiating antimicrobial therapy, provided the antimicrobials are not delayed. These cultures should include one set Essentials of Sepsis Management 357 of blood cultures drawn from any indwelling device, and a separate set drawn periph- erally. If the site of origin is not clear, prompt imaging studies should be performed, as required, to investigate suspected sources of infection, and any potential source should be sampled. Any patient suspected of being in septic shock should be immediately moved to the ICU and administered antibiotics within 1 hour. Septic shock, a result of infection and the attendant inflammatory response, is composed of metabolic derangements attrib- utable to inadequate perfusion, resulting in the buildup of lactic acid and the disruption of normal cellular function. However, the other significant challenge of the shock syndrome consists of the organism’s neuroendocrine responses aimed at restoring adequate perfusion. One of these responses, glucose dysregulation, is a common clue to the presence of an infectious source. One prospective study of 2200 trauma patients admitted to the ICU revealed a 91% positive predictive value of acute glucose elevation in the diagnosis of infection.5 This stress-induced hyperglycemia is generally seen as a transient plasma glucose level greater than 200 mg/dL and is thought to occur following increases in cortisol, glucagon, and epinephrine. Acute glucose eleva- tion should stimulate clinicians to search for a new source of infection. When septic shock is diagnosed, fluid bolus should be given, unless there is indis- putable evidence of acute left heart failure. Electrocardiogram tracing should be obtained immediately to determine the likelihood of cardiac dysfunction. Arterial blood gas should be measured, as pH will drop below neutral due to anaerobic metabolism and lactic acid accumulation, if a shock state exists. After the syndrome is recognized and resuscitation is begun, a review of the patient’s medical history is paramount to determine causation. Surgical sites must be quickly examined for erythema, drainage, bullous changes, or other signs of infec- tion. Surgeons and those caring for surgical patients should have specific knowledge of any operative procedure a patient has undergone, because this will surely help them focus on possible causes for sepsis and septic shock. If sepsis occurs in the first 24 hours after surgery, surgical site infection should be entertained. A streptococcal wound infection can quickly progress to myofascial necrosis. If this is present, radical debridement in the operating room is mandatory, supported by antibiotic therapy. SOURCE CONTROL A specific, treatable source of sepsis should always be aggressively sought and addressed as rapidly as possible. Specifically, abscess drainage, wound exploration, debridement of necrotic tissue, removal of infected implanted device, or surgical control of infectious source should occur simultaneously with resuscitation and anti- biotic administration. An identified source should always be sampled and cultured for targeted therapy. A rare exception for surgical intervention exists with pancreatic necrosis, in which delayed surgical intervention has been shown to produce better outcomes.7 Without adequate source control, resuscitative efforts will not be success- ful. Definitive operation in the case of abdominal sepsis is not as important as limiting the ongoing physiologic insult. A damage-control approach is appropriate for septic shock from abdominal sources using the same principles as the damage-control approach to trauma care.8 FLUID THERAPY AND HEMODYNAMIC SUPPORT The ultimate goal of any hemodynamic
Load more

Recommended publications
  • Sepsis: a Guide for Patients & Relatives
    SEPSIS: A GUIDE FOR PATIENTS & RELATIVES CONTENTS ABOUT SEPSIS ABOUT SEPSIS: INTRODUCTION P3 What is sepsis? In the UK, at least 150,000* people each year suffer from serious P4 Why does sepsis happen? sepsis. Worldwide it is thought that 3 in a 1000 people get sepsis P4 Different types of sepsis P4 Who is at risk of getting sepsis? each year, which means that 18 million people are affected. P5 What sepsis does to your body Sepsis can move from a mild illness to a serious one very quickly, TREATMENT OF SEPSIS which is very frightening for patients and their relatives. P7 Why did I need to go to the Critical Care Unit? This booklet is for patients and relatives and it explains sepsis P8 What treatment might I have had? and its causes, the treatment needed and what might help after P9 What other help might I have received in the Critical Care Unit? having sepsis. It has been written by the UK Sepsis Trust, a charity P10 How might I have felt in the Critical Care Unit? which supports people who have had sepsis and campaigns to P11 How long might I stay in the Critical Care Unit and hospital? raise awareness of the illness, in collaboration with ICU steps. P11 Moving to a general ward and The Outreach Team/Patient at Risk Team If a patient cannot read this booklet for him or herself, it may be helpful for AFTER SEPSIS relatives to read it. This will help them to understand what the patient is going through and they will be more able to support them as they recover.
    [Show full text]
  • Pneumonia in the Context of Severe Sepsis: a Significant Diagnostic Problem
    -1 plasma D-dimer level was low (282 mg?L ). Chest radiography affected by antiphospholipid antibodies syndrome and showed multiple ill-defined increased densities in both lower avoided diagnostic surgery. lung fields. High-resolution computed tomography was then In conclusion, we believe that the indications for use of performed and showed ill-defined, wedge-shaped increased endobronchial ultrasound are manifold and are certainly densities with patent airways in the posterior subpleural greater than those so far recognised. This procedure should regions of both lower lobes. The computed tomography therefore be implemented and further developed in interven- differential diagnosis was organising pneumonia, bronchop- tional pneumology. neumonia, Churg–Strauss syndrome, Wegener granulomato- sis, pulmonary haemorrhage, or vasculitis of various causes. Transbronchial lung biopsy was performed in the right lower G.L. Casoni, C. Gurioli, M. Romagnoli and V. Poletti lobe. Microscopic examination showed alveolar haemorrhage Thoracic Dept, G.B. Morgagni Hospital, Forlı´, Italy. without evidence of vasculitis, eosinophilic infiltration or organising pneumonia. Serum circulating antiphospholipid STATEMENT OF INTEREST antibodies were eventually found. Therefore, pulmonary None declared. angiography was performed and an intra-arterial low density was found in the right main pulmonary artery. This finding SUPPLEMENTARY MATERIAL was believed to be compatible with pulmonary thrombo- This article has supplementary material accessible from embolism; however, it didn’t exclude a possible right www.erj.ersjournals.com pulmonary artery sarcoma. In this case, the only procedure that would rule out the presence of a right pulmonary artery sarcoma (without delays in diagnosis) with any reasonable REFERENCES certainty was surgery. 1 Herth F, Becker HD, LoCicero J 3rd, Ernst A., Endobronchial We decided to perform rigid bronchoscopy under general ultrasound in therapeutic bronchoscopy.
    [Show full text]
  • What Is Sepsis?
    What is sepsis? Sepsis is a serious medical condition resulting from an infection. As part of the body’s inflammatory response to fight infection, chemicals are released into the bloodstream. These chemicals can cause blood vessels to leak and clot, meaning organs like the kidneys, lung, and heart will not get enough oxygen. The blood clots can also decrease blood flow to the legs and arms leading to gangrene. There are three stages of sepsis: sepsis, severe sepsis, and ultimately septic shock. In the United States, there are more than one million cases with more than 258,000 deaths per year. More people die from sepsis each year than the combined deaths from prostate cancer, breast cancer, and HIV. More than 50 percent of people who develop the most severe form—septic shock—die. Septic shock is a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection. Who is at risk? Anyone can get sepsis, but the elderly, infants, and people with weakened immune systems or chronic illnesses are most at risk. People in healthcare settings after surgery or with invasive central intravenous lines and urinary catheters are also at risk. Any type of infection can lead to sepsis, but sepsis is most often associated with pneumonia, abdominal infections, or kidney infections. What are signs and symptoms of sepsis? The initial symptoms of the first stage of sepsis are: A temperature greater than 101°F or less than 96.8°F A rapid heart rate faster than 90 beats per minute A rapid respiratory rate faster than 20 breaths per minute A change in mental status Additional symptoms may include: • Shivering, paleness, or shortness of breath • Confusion or difficulty waking up • Extreme pain (described as “worst pain ever”) Two or more of the symptoms suggest that someone is becoming septic and needs immediate medical attention.
    [Show full text]
  • Characteristics and Risk Factors for Intensive Care Unit Cardiac Arrest in Critically Ill Patients with COVID-19—A Retrospective Study
    Journal of Clinical Medicine Article Characteristics and Risk Factors for Intensive Care Unit Cardiac Arrest in Critically Ill Patients with COVID-19—A Retrospective Study Kevin Roedl 1,* , Gerold Söffker 1, Dominic Wichmann 1 , Olaf Boenisch 1, Geraldine de Heer 1 , Christoph Burdelski 1, Daniel Frings 1, Barbara Sensen 1, Axel Nierhaus 1 , Dirk Westermann 2, Stefan Kluge 1 and Dominik Jarczak 1 1 Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; [email protected] (G.S.); [email protected] (D.W.); [email protected] (O.B.); [email protected] (G.d.H.); [email protected] (C.B.); [email protected] (D.F.); [email protected] (B.S.); [email protected] (A.N.); [email protected] (S.K.); [email protected] (D.J.) 2 Department of Interventional and General Cardiology, University Heart Centre Hamburg, 20246 Hamburg, Germany; [email protected] * Correspondence: [email protected]; Tel.: +49-40-7410-57020 Abstract: The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing the coron- avirus disease 2019 (COVID-19) led to an ongoing pandemic with a surge of critically ill patients. Very little is known about the occurrence and characteristic of cardiac arrest in critically ill patients Citation: Roedl, K.; Söffker, G.; with COVID-19 treated at the intensive care unit (ICU). The aim was to investigate the incidence Wichmann, D.; Boenisch, O.; de Heer, and outcome of intensive care unit cardiac arrest (ICU-CA) in critically ill patients with COVID-19. G.; Burdelski, C.; Frings, D.; Sensen, This was a retrospective analysis of prospectively recorded data of all consecutive adult patients B.; Nierhaus, A.; Westermann, D.; with COVID-19 admitted (27 February 2020–14 January 2021) at the University Medical Centre et al.
    [Show full text]
  • Development of a Large Animal Model of Lethal Polytrauma and Intra
    Open access Original research Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000636 on 1 February 2021. Downloaded from Development of a large animal model of lethal polytrauma and intra- abdominal sepsis with bacteremia Rachel L O’Connell, Glenn K Wakam , Ali Siddiqui, Aaron M Williams, Nathan Graham, Michael T Kemp, Kiril Chtraklin, Umar F Bhatti, Alizeh Shamshad, Yongqing Li, Hasan B Alam, Ben E Biesterveld ► Additional material is ABSTRACT abdomen and pelvic contents. The same review published online only. To view, Background Trauma and sepsis are individually two of showed that of patients with whole body injuries, please visit the journal online 1 (http:// dx. doi. org/ 10. 1136/ the leading causes of death worldwide. When combined, 37.9% had penetrating injuries. The abdomen is tsaco- 2020- 000636). the mortality is greater than 50%. Thus, it is imperative one area of the body which is particularly suscep- to have a reproducible and reliable animal model to tible to penetrating injuries.2 In a review of patients Surgery, Michigan Medicine, study the effects of polytrauma and sepsis and test novel in Afghanistan with penetrating abdominal wounds, University of Michigan, Ann treatment options. Porcine models are more translatable the majority of injuries were to the gastrointes- Arbor, Michigan, USA to humans than rodent models due to the similarities tinal tract with the most common injury being to 3 Correspondence to in anatomy and physiological response. We embarked the small bowel. While this severe constellation Dr Glenn K Wakam; gw akam@ on a study to develop a reproducible model of lethal of injuries is uncommon in the civilian setting, med.
    [Show full text]
  • Health Care Facilities Hospitals Report on Training Visit
    SLOVAK UNIVERSITY OF TECHNOLOGY IN BRATISLAVA FACULTY OF ARCHITECTURE INSTITUTE OF HOUSING AND CIVIC STRUCTURES HEALTH CARE FACILITIES HOSPITALS REPORT ON TRAINING VISIT In the frame work of the project No. SAMRS 2010/12/10 “Development of human resource capacity of Kabul polytechnic university” Funded by UÜtà|áÄtät ECDC cÜÉA Wtâw f{t{ YtÜâÖ December, 14, 2010 Prof. Daud Shah Faruq Health Care Facilities, Hospitals 2010/12/14 Acknowledgement: I Daud Shah Faruq professor of Kabul Poly Technic University The author of this article would like to express my appreciation for the Scientific Training Program to the Faculty of Architecture of the Slovak University of Technology and Slovak Aid program for financial support of this project. I would like to say my hearth thanks to Professor Arch. Mrs. Veronika Katradyova PhD, and professor Arch. Mr. stanislav majcher for their guidance and assistance during the all time of my training visit. My thank belongs also to Ing. Juma Haydary, PhD. the coordinator of the project SMARS/2010/10/01 in the frame work of which my visit was realized. Besides of this I would like to appreciate all professors and personnel of the faculty of Architecture for their good behaves and hospitality. Best regards cÜÉyA Wtâw ft{t{ YtÜâÖ December, 14, 2010 2 Prof. Daud Shah Faruq Health Care Facilities, Hospitals 2010/12/14 VISITING REPORT FROM FACULTY OF ARCHITECTURE OF SLOVAK UNIVERSITY OF TECHNOLOGY IN BRATISLAVA This visit was organized for exchanging knowledge views and advices between us (professor of Kabul Poly Technic University and professors of this faculty). My visit was especially organized to the departments of Public Buildings and Interior design.
    [Show full text]
  • Surviving Sepsis Campaign in Your Institution: Getting Started
    Getting Started Education The SSC leadership believes that continuing education is the most important factor for initial and ongoing SSC success. A variety of educational tools is available to institutions to support the learning process. Teaching tools include: The survivingsepsis.org website will be updated as new offerings are available including webcasts, PowerPoint programs, videos, and other resources SSC educational offerings at partner society’s conferences SSC guidelines poster 2012 guidelines SSC pocket guide 2012 guidelines Bundle badge cards Surviving Sepsis Campaign lapel pins to show your team’s commitment For further assistance, please contact Stephen Davidow at the Society of Critical Care Medicine by phone at +1-847-827-7088 or by email at [email protected]. Getting Started The Surviving Sepsis Campaign In Your Institution: Getting Started The Surviving Sepsis Campaign (SSC) partnered with the Institute for Healthcare Improvement (IHI) to incorporate its “bundle concept” into the diagnosis and treatment of patients with severe sepsis and septic shock. We believe that improvement in the delivery of care should be measured one patient at a time through a series of incremental steps that will eventually lead to systemic change within institutions and larger health care systems. Local SSC implementation is the key to mortality reduction for severe sepsis and septic shock patients. Successful SSC adoption requires a hospital champion who can coordinate the LEADER steps outlined below. L Learn about sepsis and quality improvement by attending local and national sepsis meetings. E Establish a baseline in order to convince others that improvement is necessary and to make your measurements relevant.
    [Show full text]
  • Surviving Sepsis Campaign Guidelines for COVID-19
    DISCLAIMER. The information contained herein is subject to change. The final version of the article will be published as soon as approved on ccmjournal.org. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) Waleed Alhazzani1,2, Morten Hylander Møller3,4, Yaseen M. Arabi5, Mark Loeb1,2, Michelle Ng Gong6, Eddy Fan7, Simon Oczkowski1,2, Mitchell M. Levy8,9, Lennie Derde10,11, Amy Dzierba12, Bin Du13, Michael Aboodi6, Hannah Wunsch14,15, Maurizio Cecconi16,17, Younsuck Koh18, Daniel S. Chertow19, Kathryn Maitland20, Fayez Alshamsi21, Emilie Belley-Cote1,22, Massimiliano Greco16,17, Matthew Laundy23, Jill S. Morgan24, Jozef Kesecioglu10, Allison McGeer25, Leonard Mermel8, Manoj J. Mammen26, Paul E. Alexander2,27, Amy Arrington28, John Centofanti29, Giuseppe Citerio30,31, Bandar Baw1,32, Ziad A. Memish33, Naomi Hammond34,35, Frederick G. Hayden36, Laura Evans37, Andrew Rhodes38 Affiliations 1 Department of Medicine, McMaster University, Hamilton, Canada 2 Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada 3 Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark 4 Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) 5 Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia 6 Department of Medicine, Montefiore Healthcare
    [Show full text]
  • Package for Emergency Resuscitation and Intensive Care Unit
    Package for Emergency Resuscitation and Intensive Care Unit Extracted from WHO manual Surgical Care at the District Hospital and WHO Integrated Management for Emergency & Essential Surgical Care toolkit For further details and anaesthetic resources please refer to full text at: http://www.who.int/surgery/publications/imeesc/en/index.html 1 1. Anaesthesia and Oxygen XYGEN KEY POINTS: • A reliable oxygen supply is essential for anaesthesia and for any seriously ill patients • In many places, oxygen concentrators are the most suitable and economical way of providing oxygen, with a few backup cylinders in case of electricity failure • Whatever your source of oxygen, you need an effective system for maintenance and spares • Clinical staff need to be trained how to use oxygen safely, effectively and economically. • A high concentration of oxygen is needed during and after anaesthesia: • If the patient is very young, old, sick, or anaemic • If agents that cause cardio-respiratory depression, such as halothane, are used. Air already contains 20.9% oxygen, so oxygen enrichment with a draw-over system is a very economical method of providing oxygen. Adding only 1 litre per minute may increase the oxygen concentration in the inspired gas to 35–40%. With oxygen enrichment at 5 litres per minute, a concentration of 80% may be achieved. Industrial-grade oxygen, such as that used for welding, is perfectly acceptable for the enrichment of a draw-over system and has been widely used for this purpose. Oxygen Sources In practice, there are two possible sources of oxygen for medical purposes: • Cylinders: derived from liquid oxygen • Concentrators: which separate oxygen from air.
    [Show full text]
  • PIM2) in Argentina: a Prospective, Multicenter, Observational Study
    Original article Validation of the Pediatric Index of Mortality 2 (PIM2) in Argentina: a prospective, multicenter, observational study Ariel L. Fernández, M.Sc.,a María P. Arias López, M.D.,b María E. Ratto, M.D.,c Liliana Saligari, M.D.,d Alejandro Siaba Serrate, M.D.,e Marcela de la Rosa, M.D.,f Norma Raúl, M.D.,g Nancy Boada, M.D.,h Paola Gallardo, M.D.,i InjaKo, M.D.,b and Eduardo Schnitzler, M.D.e ABSTRACT and the different investments made Introduction. The Pediatric Index of Mortality 2 by each region in their healthcare (PIM2) is one of the most commonly used scoring systems to predict mortality in patients systems. Critical care distribution and admitted to pediatric intensive care units (PICU) quality are not homogeneous within in Argentina. The objective of this study was to each country either, which leads to validate the PIM2 score in PICUs participating differences in results and a likely in the Quality of Care Program promoted by the Argentine Society of Intensive Care. impact on overall health indicators, Population and Methods. Multicenter, such as child mortality rates.1 prospective, observational, cross-sectional study. In order to implement any quality All patients between 1 month and 16 years old improvement initiative, results should a. FUNDASAMIN admitted to participating PICUs between January (Fundación para 1st, 2009 and December 31st, 2009 were included. be objectively measured. Prognostic la Salud Materno The discrimination and calibration of the PIM2 scores of mortality in intensive care Infantil). score were assessed in the entire population and units (ICU) have been developed to b.
    [Show full text]
  • Sleep in the Intensive Care Unit Setting
    Crit Care Nurs Q CONTINUING EDUCATION Vol. 31, No. 4, pp. 309–318 Copyright c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sleep in the Intensive Care Unit Setting Maulik Patel, MD; Joseph Chipman, MD; Brian W. Carlin, MD; Daniel Shade, MD Sleep is essential to human life. Sleep patterns are significantly disrupted in patients who are hos- pitalized, particularly those in the intensive care unit. Sleep deprivation is pervasive in this patient population and impacts health and recovery from illness. Immune system dysfunction, impaired wound healing, and changes in behavior are all observed in patients who are sleep deprived. Vari- ous factors including anxiety, fear, and pain are responsible for the sleep deprivation. Noise, light exposure, and frequent awakenings from caregivers also add to these effects. Underlying medical illnesses and medications can also dramatically affect a patient’s ability to sleep efficiently. Ther- apy with attempts to minimize sleep disruption should be integrated among all of the caregivers. Minimization of analgesics and other medications known to adversely affect sleep should also be ensured. Although further research in the area of sleep deprivation in the intensive care unit set- ting needs to be conducted, effective protocols can be developed to minimize sleep deprivation in these settings. Key words: critical care, deprivation, disruption, immune dysfunction, sleep LEEP is vital for basic survival in humans. NORMAL SLEEP S One third of each person’s life is spent asleep. All body systems require an adequate Normal sleep architecture is divided into amount of sleep to maintain proper function 2 phases, nonrapid eye movement (NREM) and any disruption in the sleep cycle can dra- and rapid eye movement (REM) (Fig 1).
    [Show full text]
  • Tracheal Intubation in Critically Ill Patients
    Cabrini et al. Critical Care (2018) 22:6 https://doi.org/10.1186/s13054-017-1927-3 RESEARCH Open Access Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials Luca Cabrini1,2, Giovanni Landoni1,2, Martina Baiardo Redaelli1, Omar Saleh1, Carmine D. Votta1, Evgeny Fominskiy1,3, Alessandro Putzu4, Cézar Daniel Snak de Souza5, Massimo Antonelli6, Rinaldo Bellomo7,8, Paolo Pelosi9* and Alberto Zangrillo1,2 Abstract Background: We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. Methods: We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation- based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration’s Risk of Bias tool. Results: We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study).
    [Show full text]